The Feminist Health CIC

Some Definitions:

Empowerment is “the expansion in people’s ability to make strategic life choices in a context where this ability was previously denied to them” (Kabeer, 2001).

Gender refers to the socially constructed roles, expectations and definitions a given society considers appropriate for men and women. Male gender norms are the social expectations and roles assigned to men and boys in relation to or in contrast to women and girls. 

Masculinity refers to the multiple ways that manhood is socially defined across the historical and cultural context and to the power differences between specific versions of manhood (Connell, 1994).

Patriarchy refers to historical power imbalances and cultural practices and systems that accord men on aggregate more power in society and offer men material benefits, such as higher incomes and informal benefits, including care and domestic service from women and girls in the family (United Nations Division for the Advancement of Women, 2003). 

Over the years, maternal health issue have often been viewed as a gender issue. Most of the interventions have aimed at women empowerment, increasing female autonomy and their decision-making powers. But improving women autonomy alone has not always been associated with increased utilisation of maternal health services, especially in low income countries. Yet in that socio-cultural context, men still hold a lot of power in decision-making in the family.

In fact empowerment has two critical dimensions: process, which refers to a shift “toward greater equality, or greater freedom of choice and action” and agency: women themselves must be significant actors in the process of change that is being described or measured. In this context, “disempowered women” refers to those who, due to social and structural processes beyond their control, do not have the ability to act on their desires.

Male involvement in maternal health has been recognized as a promising strategy in improving maternal and child health and globally it has been associated with positive reproductive health outcomes. Despite these benefits, few men participate in women health services and decision making. 

This is because maternal healthcare has always been considered a field of only female interest and even nowadays there is still places where men are barely involved . This has led women to be the basic target in most of the health education and awareness programs and men tend to be excluded. 

During the last decade there has been a growing interest in engaging men in reproductive health, as shown in different meeting and congress:

• The International Conference on Population and Development held in Cairo in 1994 where 179 nations agreed to a Plan of Action that included specific steps towards both empowering women and enhancing men’s support. Specifically, the Plan stated: “Changes in both men’s and women’s knowledge, attitudes, and behavior are necessary conditions for achieving a harmonious partnership of men and women. This would open the door to gender equality in all spheres of life, including improving communication between men and women on issues of sexuality and reproductive health, and improving understanding of their joint responsibilities “(UN-FPA 2004).

• The Fourth World Conference on Women held in Beijing in 1995, where it was emphasized that men’s attitudes, knowledge, and ways of reacting, influence not only their own but also women’s reproductive health

•  in 2000, the United Nations General Council adopted eight Millennium Development Goals, a process which is intended to generate government and civil society momentum to meet the needs of the world’s poorest citizens. Goal 5 was to improve Maternal Health

•  World Health Organization (WHO) states that interventions promoting male involvement in maternal and child health should be implemented provided that they respect, promote and facilitate women’s choices and their autonomy in decision-making 

There are some different factors that drives the lack of men contribution in maternal healthcare in low- and high-income countries.

In developed countries men often feel marginalized in their contact with the mother and infant services because childbirth or parent education classes focus exclusively on women and motherhood (Platin et al., 2011). Not only this, but men feel a “sense of insufficiency, inadequacy, anxiety and insecurity”. Instead the active participation of the father shows a beneficial to the mothers: counteract maternal and infant mortality or problem to relation to pregnancy,  ability for women to get immediate care in obstetric emergiencies, psychological and practical support and sharing responsibility for the child following the birth to newborn

On the other end, although data in maternal death show a declining trend over the last three decades, it still accounts 99% of global maternal mortality in low- and middle-income countries. The vast majority of maternal deaths (80 percent) are due to complications during pregnancy, at delivery or within six weeks post-delivery. The presence of HIV further complicates the situation.

Men in these countries play the role of gatekeepers to health care and their decision affects utilization of resources and access to health care services, use of contracceptives, availability of nutritions food and women’s workload. Factors founded to be involved in very low participation of men in under-developed countries are:

1. Poverty and gender: These factors are very linked together, as poverty lead to gender inequality and have negative effects on maternal healthcare access and utilization in multiple ways. However, gender inequalities contributes to institutional or structural factors such as culture, social norms and discrimination that, in turn, affect women’s individual ability to act on their own behalf (agency)(individual autonomy, ability to make decisions, control over vital resources, gender-based violence, gender divisions of labour, lack of access to and control over resources and gender norms)
2. Cost of care (including transport)
3. Location of facilities
4. Quality of care
5. Social cultural values: The belief that child-birth and delivery are perceived by men as woman’s affair; family members and peers influence.
6. Lack of support from men during pregnancy.
7. Negative attitudes towards fatherhood 
8. Domestic violence and perceptions of women’s attitudes and behaviour during pregnancy: Failure to perform their house-hold chores as well as decreased interest in sex from women when pregnant; negative attributes assigned to women included aggressiveness, quarrelling, laziness, extravagance, rudeness, and dirtiness when they are pregnant.
9. Health worker attitudes and behaviour: Rudeness and abusive behaviour by health workers.
10. Lack of space privacy

In addition, because of the role men play in decision making in the family, some researchers suggest that male involvement is a very significant factor to consider in finding a solution to the three main factors responsible for many of the maternal death: 

11. The delay in decision-making to refer the patients to health facility for treatment: Most of the time, women who exercise some level of autonomy are considered disrespectful, disrupting the social hierarchy and challenge the power structure. And often the lack of urgency in the decision making process is due to the woman economic dependence on their husbands.
12. Lack of transport in case of obstetric complications; and 
13. Delay in receiving treatment within the health care facility, which is sometimes related to covering the costs associated to such emergencies.

Several programmes and strategies have been made, like group education (discussion, educational  or awarness-raising session), service based programme (involving health services) or integrated programme (mixed of the previous) ; and these can be gender neutral, with a minimal analysis of how men and women health related needs differ, gender sensitive( evidence of men specific needs and gender transfromative ( discussing gender, social contrusct and masculinity norms). 

Although all this, there is still much to achieve, data to collect and analysis to do. 

There is the need for governments and institutions to put more effort to investigate these situations globally and  to guarantee an increase of coverage of services, quality of care, the decrease of healthcare cost and mainly transform gender norms that undermine the ability of women to seek for maternal health care and foster and support the  women empowerment.

References

[1]       World Health Organization. Policy approaches to engaging men and boys in achieving gender equality and health equality. 2010.

[2]       Namasivayam A, Osuorah DC, Syed R AD. The role of gender inequities in women’s access to reproductive health care: a population-level study of Namibia, Kenya, Nepal, and India. Nternational J Women’s Heal 2012:351–64.

[3]       R C. Masculinities. Berkeley, 1994;University.

[4]       Terefe A LC. Modern contraception use in Ethiopia: does involving husbands make a difference? Am J Public Heal 1993:156–71.

[5]       Danforth E, Kruk M, Rockers P, Mbaruku G GS. Household decision- making about delivery in health facilities: evidence from Tanzania. J Heal Popul Nutr 2009;27:696.

[6]       Olayemi O, Bello FA, Aimakhu CO, Obajimi GO AA. Male participation in pregnancy and delivery in Nigeria: a survey of antenatal attendees. J Biosoc Sci 2009;41:493–503. doi:10.1017/S0021932009003356.

[7]       Waiswa P, Kemigisa M, Kiguli J, Naikoba S, Pariyo GW PS. Acceptability of evidence-based neonatal care practices in rural Uganda– implications for programming. 2008;8:21. BMC Pregnancy Childbirth 2008:21.

[8]       AA. B. Spousal communication and family planning behavior in Navrongo: a longitudinal assessment. Stud Fam Plan 2002:185–94. doi:doi:10. 1111/j.1728-4465.2002.00185.x.

[9]       Plantin, L., Månsson, S-A., & Kearney J. Talking and doing fatherhood. On fatherhood and Masculinity in Sweden and Britain. Fathering 2003;1:3–26.

[10]     Pisacane A, Continisio GI, Aldinucci M, D’Amora S CP. A controlled trial of the father’s role in breastfeeding promotion. Pediatrics 2005;116:494–8. doi:10.1542/peds.2005-0479.

[11]     M. C. Husband involvement in the treatment of child illness in Guatemala. Cart M 2004;36:189–208.

[12]     Muheirwe F, Nuhu S. Men’s participation in maternal and child health care in Western Uganda: Perspectives from the community. BMC Public Health 2019;19:1–10. doi:10.1186/s12889-019-7371-3.

[13]     L. P. upplevelser och erfarenheter av faderskapet [Men’s parenting. On men’s perceptions and experiences of fatherhood]. PhD thesis. Göte- borg University: Inst. för socialt arbete. 2001.

[14]     N. K. Resources, Agency, Achievements: Reflections on the Measurement of Women’s Empowerment. In Discussing Women’s Empowerment – Theory and Practice, edited by A Sisask, Stockholm: Novum Grafiska. 2001:17–57.

[15]     Greene ME, Mehta M, Pulerwitz J, Wulf D, Bankole A SS. Involving Men in Reproductive Health: Contributions to Development., Millennium Project 2006.

[16]     Malhotra A and SS. Women’s Empowerment as a Variable in International Development. In Measuring Empowerment: Cross-Disciplinary Perspectives, edited by D Narayan, 71-88. Washington, DC World Bank 2005:71–88.

[17]     Sharma M PR. Impact of expectant fathers in breast-feeding decisions. J Am Diet Assoc 1997;97:1311–3. doi:10.1016/S0002-8223(97)00312-X.

[18]     Comrie-Thomson L, Tokhi M AF et al. Challenging gender in- equity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Culture, Health & Sexuality 2015;17:177–89.

[19]     Early R. Men as consumers of maternity services: A contradiction in terms. Int J Consum Stud 2001;25:160–7.

[20]     Babirye JN, Rutebemberwa E, Kiguli J, Wamani H, Nuwaha F EI. More support for mothers: a qualitative study on factors affecting immunisation behaviour in Kampala, Uganda. BMC Public Heal 2011:723.

[21]     Aniebue PN, Aniebue UU AG. Knowledge and beliefs about exclusive breastfeeding among rural Nigerian men in Enugu, Southeast Nigeria. Breastfeed Med 2010;5:169–71. doi:10.1089/bfm.2009.0082.

[22]     Lester, A., & Moorsom S. Men and midwifery. Do men need midwifes: facilitating a greater involvement in parenting. Br J Midwifery 1997;5:678–81.

[23]     Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PLoS One 2018;13:1–16. doi:10.1371/journal.pone.0191620.

[24]     Gross K, Alba S, Glass TR, Armstrong Schellenberg J OB. Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. BMC Pregnancy Childbirth 2012;12:12–6. doi:10.1186/1471-2393-12-16.

[25]     Singh D, Lample M, Earnest J. The involvement of men in maternal health care: Cross-sectional, pilot case studies from Maligita and Kibibi, Uganda. Reprod Health 2014;11:1–8. doi:10.1186/1742-4755-11-68.

[26]     McMahon SA, George AS CJ et al. Experiences of and responses to disrespectful maternity care and abuse during childbirth; a qualitative study with women and men in Morogoro Region, Tanzania. BMC Pregnancy Childbirth 2014;14.

[27]     Kariuki K, Seruwagi G. Determinants of Male Partner Involvement in Antenatal Care in Wakiso District, Uganda. Br J Med Med Res 2016;18:1–15. doi:10.9734/bjmmr/2016/28056.

[28]     M K. The gendered society. Oxford, Oxford University Press. 2000.

[29]     ST. P. Together, we can: the success of the Migende practice model for preventing parent-to-child transmission of HIV in Papua New Guinea. Bangkok: UNICEF. 2011.

[30]     Tolhurst R, Raven J TS. Gender equity: perspectives on mater- nal and child health. Matern Child Heal Springer 2009;In: Ehiri:151–66.

[31]     Finnbogadóttir, H., Crang Svalenius, E., & Persson E. Expectant first-time fathers’ ex- periences of pregnancy. Midwifery 2003:96–05.

[32]     Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tanner M et al. Factors affecting home delivery in rural Tanzania. Trop Med Int Heal 2007;12:862–72. doi:10.1111/j.1365-3156.2007.01855.x.

[33]     Khan ME PB. Male involvement in family planning: a KABP Study of Agra District, Uttar Pradesh. New Delhi: Population Council. 1997.

[34]     Chalmers, B., & Mayer D. What men say about pregnancy, birth and parenthood. J Psychosom Obstet Gynaecol 1996;17:47–52.

[35]     Nanjala M, Wamalwa D. Determinants of male partner involvement in promoting deliveries by skilled attendants in Busia, Kenya. Glob J Health Sci 2012;4:60–7. doi:10.5539/gjhs.v4n2p60.

[36]     Barker G RC. Young men and the construction of masculinity in sub-Saharan Africa: implications for HIV/AIDS, con ict and violence. Washington, DC, World Bank. 2005.

[37]     Women UND for the A of. The role of men and boys in achieving gender equality. Report of the expert group meeting, Brasilia, Brazil, 21-24 October, 2003. New York, United Nations 2003.

[38]     Organization WH. WHO recommendations on health promotion interventions for maternal and newborn health. Geneva. 2015.

[39]     Yargawa J, Leonardi-Bee J. Male involvement and maternal health outcomes: Systematic review and meta-analysis. J Epidemiol Community Health 2015;69:604–12. doi:10.1136/jech-2014-204784.

[40]     G. B. What about boys? A literature review of the health and development of adolescent boys. Geneva, World Health Organization (WHO/FCH/CAH/00.7;) 2000. doi:http://whqlibdoc.who.int/hq/2000/WHO_FCH_CAH_00.7.pdf, accessed 2 April 2007.

[41]     J B. Confronting maternal mortality, controlling birth in Nepal: the gendered politics of receiving biomedical care at birth. Soc Sci Med 2010;71:1719–27. doi:0.1016/j.socscimed.2010.06.013.

[42]     WHO. World Health Organization. WHO recommendations on health promotion interventions for maternal and newborn health. Geneva: WHO. 2015.

[43]     Plantin L, Olukoya AA, Ny P. Positive Health Outcomes of Fathers’ Involvment in Pregnancy and Childbirth Paternal Support: A Scope Study Literature Review. Father A J Theory, Res Pract about Men as Father 2011;9:87–102. doi:10.3149/fth.0901.87.

[44]     Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M LS. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PLoS One 2018;13. doi:e0191620.

[45]     Morgan R, Tetui M, Kananura RM, Ekirapa-Kiracho E, George AS. Gender dynamics affecting maternal health and health care access and use in Uganda. Health Policy Plan 2017;32:v13–21. doi:10.1093/heapol/czx011.

[46]     Rivers K AP. Men and the HIV epidemic, gender and the HIV epidemic. New York, HIV and Development Programme, United Nations Development Programme. 1998.

[47]     M K. The gendered society. Oxford, 2000.

[48]     Aborigo RA, Reidpath DD, Oduro AR, Allotey P. Male involvement in maternal health: Perspectives of opinion leaders. BMC Pregnancy Childbirth 2018;18:1–10. doi:10.1186/s12884-017-1641-9.

[49]     Sharma S, Bhuvan KC, Khatri A. Factors influencing male participation in reproductive health: A qualitative study. J Multidiscip Healthc 2018;11:601–8. doi:10.2147/JMDH.S176267.

[50]     M K. Cracking the armour: power, pain and the lives of men. Toronto. Viking 1993.

[51]     Pembe AB, Urassa DP, Darj E, Carlsted A OP. Qualitative study on maternal referrals in rural Tanzania: decision making and acceptance of referral advice. Afr J Reprod Heal 2008;12:120–31.

[52]     Mpembeni RN, Killewo JZ, Leshabari MT, Massawe SN, Jahn A, Mushi D et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth 2007. doi:10.1186/1471-2393-7-29.

[53]     Dutta M, Kapilashrami MC TV. Knowledge, awareness and extent of male participation in key areas of reproductive and child health in an urban slum of Delhi. Heal Popul Perspect Issues 2004;27:49–66.

[54]     Osamor PE GC. Women’s autonomy in health care decision- making in developing countries: a synthesis of the literature. Int J Womens Heal 2016:191–202.

[55]     Aborigo RA, Reidpath DD, Oduro AR, Allotey P. Male involvement in maternal health: Perspectives of opinion leaders. BMC Pregnancy Childbirth 2018;18:1–10. doi:10.1186/s12884-017-1641-9.

[56]     Mullany BC, Hindin MJ, Becker S. Can women’s autonomy impede male involvement in pregnancy health in Katmandu, Nepal? Soc Sci Med 2005;61:1993–2006. doi:10.1016/j.socscimed.2005.04.006.

[57]     W M. Adolescent male sexuality and heterosexual masculinity: a conceptual model and review. J Adolesc Res 1988:285–303.

[58]     Peneza AK, Maluka SO. ‘Unless you come with your partner you will be sent back home’: strategies used to promote male involvement in antenatal care in Southern Tanzania. Glob Health Action 2018;11. doi:10.1080/16549716.2018.1449724.

[59]     Kraft JM, Wilkins KG, Morales GJ, Widyono M MS. An evi- dence review of gender-integrated interventions in reproductive and maternal- child health. Ournal Heal Commun 2014;19:122–41.

[60]     R C. Gender and power. Stanford, 1987.

[61]     Natoli L, Holmes W, Chanlivong N, Chan G TM. Promoting safer sexual practices among expectant fathers in the Lao People’s Democratic Republic. Glob Public Heal 2012:299–311. doi:10.1080/17441692.2011.641987.

[62]     Milligan R, Wingrove BK, Richards L, Rodan M, Monroe-Lord L, Jackson V et al. Perceptions about prenatal care: views of urban vulnerable groups. BMC Public Heal 2002:25.

[63]     Silvia Paruzzolo, Rekha, Aslihan Kes CA. Targeting Poverty and Gender Inequality To Improve Maternal Health. 2010.

[64]     Abosse Z, Woldie M OS. Factors Influencing Antenatal Care Service Utilization in Hadiya Zone. Ethiop J Heal Sci 2010;20:75–82.

[65]     Farquhar C, Kiarie JN, Richardson BA, Kabura MN, John FN, Nduati RW et al. Antenatal Couple Counseling Increases Uptake of Interventions to Prevent HIV-1 Transmission. J Acquir Immune Defic Syndr 1999 2004:1620–6.

[66]     Gary Barker CR and MN. Engaging men and boys in changing gender-based inequity in health: evidence from programme intervensions. 2007.

[67]     Singh K, Bloom S BP. Gender equality as a means to improve maternal and child health in Africa. Health Care Women Int 2015:57–69.

[68]     Davis J, Vyankandondera J, Luchters S, Simon D, Holmes W. Male involvement in reproductive, maternal and child health: A qualitative study of policymaker and practitioner perspectives in the Pacific. Reprod Health 2016;13:1–11. doi:10.1186/s12978-016-0184-2.